Comorbid Diagnoses: When Other Illnesses Occur Alongside an Eating Disorder

I often remind the readers of this blog that eating disorders are complex illnesses with physical, psychological and sociocultural roots and implications. Yet another reason supporting this complexity is the elevated incidence of eating disorder comorbidities. In other words, other psychiatric and medical conditions often present alongside anorexia nervosa, bulimia nervosa and binge eating disorder. In many cases, the two diagnoses are intertwined in some way, with one illness having contributed to the development of the other condition.

Common eating disorder comorbidities include:

Depression and anxiety. Disordered eating behaviors like restricting intake, purging or food rituals can serve as powerful stress relievers for those suffering with anxiety and depression. Research suggests that roughly two-thirds of patients admitted to eating disorders treatment programs will also meet diagnostic criteria for depression and/or anxiety. For half of these patients, the depression and anxiety predated the onset of the eating disorder, indicating that the mood disorder may have been the first illness to occur.[1] Additionally, there has been found to be a higher incidence of major depression in first-degree relatives of people with eating disorders.[2]

Obsessive-compulsive disorder (OCD). Eating disorders symptoms can often mirror OCD symptoms. Rigidity, compulsivity and the creation of elaborate rituals around food and exercise often display in both diagnoses. In fact, 40 percent of patients seeking eating disorders treatment will meet diagnostic criteria for OCD.[3]

Bipolar disorder. Seen most commonly alongside bulimia, bipolar disorder shares several key symptoms with bulimia, including weight issues and impulsivity. Researchers have also found a correlation between the severity of an individual's bipolar symptoms and the likelihood they will develop disordered eating behaviors.[4]

Substance abuse. Abuse of drugs and alcohol offers a mechanism for those suffering from eating disorders to numb their pain and anxiety. The use of substances that decrease or suppress appetite in an effort to manage weight tends to be an anorexia comorbidity, while the abuse of substances with no effect on appetite or weight tends to be a bulimia comorbidity. Research suggests that 25 percent of individuals entering treatment for eating disorders will meet criteria for substance abuse problems, as well as a higher incidence of substance abuse in first-degree relatives of people with eating disorders.[5]

Medical comorbidities. In addition to these psychiatric comorbidities, certain medical conditions commonly occur alongside eating disorders. Bone disease, cardiac complications, gastrointestinal distress and various other organ problems can emerge as co-occurring complications associated with starvation and purging. Diabetes has also become a common eating disorder comorbidity, so much so that the media -- and some members of the medical community -- have adopted the term "diabulimia," which refers to the deliberate manipulation of insulin to help diabetics lose weight or maintain a desired weight.

Understanding how comorbid conditions are intertwined with an eating disorder and treating both the eating disorder and co-occurring illness are critical to lasting recovery. It also highlights the important role of both medical and psychiatric physicians in the treatment process. Comprehensive eating disorders treatment should involve a collection of extensive information regarding past diagnoses and medications, as well as psychiatric and medical screenings upon admission. This information helps the treatment team craft an individualized treatment plan for each patient that recognizes the eating disorder and other diagnoses. However, when comorbidities are present, the initial objective of treatment is psychiatric and medical stabilization, which must be achieved before patients can meaningfully engage in the therapeutic recovery process.

Have questions about eating disorders and comorbid conditions? Confidentially chat live with an eating disorders specialist at EatingRecoveryCenter.com.

If you're struggling with an eating disorder, call the National Eating Disorders helpline at 1-800-931-2237.

For more by Kenneth L. Weiner, M.D., FAED, CEDS, click here.

For more on eating disorders, click here.

References:

[1] Blinder, Cumella & Sanathara, "Psychiatric comorbidities of female inpatients with eating disorders." Psychosom Med. 2006 May-Jun;68(3):454-62.

[2] Mazzeo SE, Bulik CM. "Environmental and genetic risk factors for eating disorders: what the clinician needs to know." Child Adolesc Psychiatric Clin N Am 2008; 18: 67-82.

[3] Blinder, Cumella & Sanathara, "The Importance of Addressing OCD and Other Anxiety Disorders Symptoms in the Treatment of Eating Disorders." 2006.

[4] Baek, J. H., Park, D. Y., Choi, J., Kim, J. S., Choi, J. S., Ha, K., Hong, K. S. (2011). "Differences between bipolar I and bipolar II in clinical features, comorbidity, and family history." Journal of Affective Disorders, 131, 59-67.

[5] Kaye, W., and Wisniewski, L. 1996. "Vulnerability to Substance Abuse in Eating Disorders." NIDA.159, 269-311.

 

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Comments

[NorthernCalifornian]

05:10 PM on 08/22/2012

People who become semi-starved experience dramatic changes in mood and personality. In the Minnesota Starvation Study, for example, individuals who lost a significant amount of weight all began to show serious psychological problems, including irritability, impatience, dislike of other people, introversion, loss of energy, dizziness, tiredness, reduced coordination, ringing in the ears, loss of motivation, neurological deficits, loss of ambition, and self-harm. One person chopped off three of his fingers due solely to the anxiety caused by semi-starvation. Others were committed to a psychiatric hospital. It's now known, therefore, that many -- perhaps all -- psychological features associated with restricting-type anorexia nervosa are the consequence of semi-starvation, not a co-morbid psychiatric disorder.

Read about the Minnesota experiment at http://jn.nutrition.org/content/135/6/1347.full


Fortunately, the psychological problems associated with semi-starvation are reversible. All the participants in the Minnesota Study were completely relieved of their symptoms upon weight restoration and resumption of normal eating patterns. Refeeding was not easy. It required several months. During refeeding, the psychological distress was temporarily amplified. Long term, though, all of the subjects regained psychological health and lived happy, healthy lives.
One lesson from the experiment is that people who suffer from anorexia nervosa (and their families) should not assume that the psychological problems associated with AN are a co-morbid psychiatric disorder. They may instead be the reversible effects of semi-starvation.

[JulieGreene]

02:43 PM on 08/16/2012

Hi, thank you for bringing this to public attention. The question is, which came first, the eating disorder, or the other condition...and does it matter? If one caused the other, then you'd figure that that one would be the one to attack.

Please do not forget psychotic disorders. Some of us do have them. I have schizoaffective disorder, which I struggle to acknowledge.

[JulieGreene]

02:38 PM on 08/16/2012

Thank you for bringing this to light. You say "co-occurring" which is very interesting because we don't really know if one causes the other, but obviously they feed into each other. My guess is that it is different in each individual case. Also, I do not see evidence (in my experience) of there always being some trauma involved, as some insist, or particular personality traits. Once you tap under the surface of someone with an eating disorder, you see that everyone is very, very different and has a different story to tell. This may be part of the reason why these disorders are so difficult to treat.

Please do not forget about psychotic disorders. Some of us have those, too. I have schizoaffective, or so they say.

Julie